Conditions

Back Pain

Overview

Back pain is one of the leading reasons for doctor visits and lost days from work. Each year, nearly $1 billion dollars are spent on treating back pain, lost wages, litigation, and disability in this country.

Back pain will typically affect 4 out of 5 people during their lifetimes, and is the leading cause of work related disability in the U.S. Fortunately, instances of back pain are often self-limiting and resolve on their own without the need for surgery. Conservative treatment should almost always be tried when back pain doesn’t resolve within a week or two.

Causes

Causes of back pain range from soft tissue injury, such as pulled muscles, to injuries to the deeper structures that comprise the actual skeleton and its supportive structures, such as disc herniations.

The cause must be identified if proper treatment is to be provided, as the treatment is obviously dependent on the cause.

Here are some of the most common causes of back pain:

Herniated disk. This occurs when disk material presses on a nerve.

Sciatica. This condition often occurs when a herniated disk impinges on the sciatic nerve causing sharp, shooting pain through the buttocks and back of the leg.

Spinal stenosis. This condition occurs when the space around the spinal cord and nerve roots narrows due to arthritis and bone overgrowth. This can press or pinch a nerve.

Spondylosis. Spondylosis is a type of arthritis affecting the spine. It is due to the degenerative changes in the spine that often come with aging.

Spondylolisthesis. This condition occurs when one vertebra in the spinal column slips forward over another.

Cauda equina syndrome. This is a serious neurological problem causing weakness in the legs, numbness in the "saddle" or groin area, and loss of bowel or bladder control.

Cancer in the spine. A tumor on the spine can press on a nerve causing back pain.

Infection of the spine. If a fever and a tender, warm area accompany back pain, the cause could be an infection.

Injury. Damage to the bones, ligaments, or muscles of the back can cause severe pain.

Failed spinal surgery can be a severe cause of debilitating back pain.

Seeking Medical Advice

Most instances of back pain gradually improve with home treatment and self-care. Although it may take several weeks before it completely resolves, you should notice some improvement within the first 72 hours of self-care. If not, see your doctor.

In rare cases, back pain can signal a serious medical problem. See a doctor immediately if your back pain:

is constant or intense, especially when lying down at night, or walking

is associated with weakness or numbness in the legs, or feet

is associated with loss of bowel or bladder function

is associated with fever or night sweats

is associated with trauma

is accompanied by unexplained weight loss

is associated with abdominal pain and pulsating feeling

Screening and Diagnosis

When a patient presents to a physician with back pain, a careful history of the pain should be taken, in which precipitating causes, and other important factors are evaluated. Other medical conditions that the patient may have should also be considered when back pain is the symptom. In addition, a physical examination should be performed, as well as a review of any diagnostic tests the patient may have already undergone. All of the above is taken into consideration in order to make the correct diagnosis, and formulate an appropriate treatment plan.

Often times, a physician may for many reasons, order one or more diagnostic tests:

X-ray. These images show the alignment of your bones and whether you have degenerative joint disease or broken bones. X-ray images won't directly show problems with your spinal cord, muscles, fibrous tissues (fascia), nerves or disks.

Bone scan. In rare cases, your doctor may use a bone scan to look for bone tumors or compression fractures caused by osteoporosis. In this procedure, you'll receive an injection of a small amount of a radioactive substance (tracer) into one of your veins. The substance collects in your bones and allows your doctor to detect bone problems using a special camera.

Nerve studies (electromyography, or EMG). This test measures the electrical impulses produced by the nerves and the responses of your muscles. Studies of your nerve-conduction pathways can confirm nerve compression caused by herniated disks or narrowing of your spinal canal (spinal stenosis).

Treatment

Most cases of back pain get better with a few weeks of home treatment and careful attention. A short course of anti-inflammatory and hot or cold therapy may be all that you need to improve your pain. A short period of bed rest is okay, but more than a couple of days actually does more harm than good. If home treatments aren't working, your doctor may suggest stronger medications or other therapy.

Medications and Therapies

Physical therapy and exercise. A physical therapist can apply a variety of treatments, such as heat, ice, ultrasound, electrical stimulation, and muscle release techniques, to your back muscles and soft tissues to reduce pain. As pain improves, the therapist can teach you specific exercises to increase your flexibility, strengthen your back and abdominal muscles, and improve your posture. Regular use of these techniques will help pain from recurring.

Prescription medications. Your doctor may prescribe nonsteroidal anti-inflammatory drugs or in some cases, and possibly a muscle relaxant, to relieve mild to moderate back pain that doesn't get better with over-the-counter pain relievers.

Cortisone injections. If pain isn't relieved using other measures and you have pain radiating down your leg from a "pinched nerve," your doctor may prescribe cortisone injections — an anti-inflammatory medication — into the space around your spinal cord (epidural space). A cortisone injection helps decrease inflammation around the nerve roots.

Electrical stimulation. A procedure called transcutaneous electrical nerve stimulation (TENS) uses a unit that sends a weak electrical current through specific points on the skin to nerve pathways. This is thought to interrupt pain signals, preventing them from reaching your brain. Although safe and painless, TENS doesn't work for everyone or for all types of pain. It's generally more effective for acute pain than for chronic pain and is often used with other treatments. TENS may be a good option to try for people who can't take or don't get relief from medications.

Back schools. These programs, available in many communities, focus on managing back pain and preventing its recurrence. Classroom study generally involves back anatomy and function, followed by practice sessions on how to protect your back at home and work.

Treating Chronic Back Pain
Treatment for chronic back pain may also include using:

Antidepressant medications. Low doses of certain types of antidepressants have been shown to relieve pain, independent of their effect on depression.

Narcotics (opioids). These medications, such as codeine or hydrocodone, may be used for a short period of time with close supervision by your doctor.

Nerve blocks. These procedures range from simple injections of local anesthetic often combined with a cortisone-like preparation, to very precise targeted nerve blocks aimed at the specific “pain generator” and performed under fluoroscopy. Epidural and facet injections are c ommon examples of nerve blocks performed to in diagnosing and treating painful conditions.

Radiofrequency Ablation. Is a procedure performed after successful temporary reduction of pain has been achieved with diagnostic nerve blocks. These procedures are usually performed using special equipment, including a radiofrequency machine, fluoroscopy to visualize exactly where the needle is located, and under intravenous sedation to ensure the patient’s comfort and safety.

Surgical and Other Procedures
Few people ever need surgery for back pain. There are no effective surgical techniques for muscle- and soft-tissue-related back pain. Surgery is usually reserved for pain caused by a herniated disk. If you have unrelenting pain or progressive muscle weakness caused by nerve compression, you may benefit from surgery. Types of back surgery include:

Laminectomy and Laminotomy. These procedures involve removing part of your vertebra — the bony part of your spinal column. This procedure may relieve leg pain caused by bone spurs or disk fragments that protrude into your spinal canal or press on nerve roots within your spine.

Intradiscal electrothermal therapy (IDET). In this treatment, doctors insert a needle through a catheter into the disk. The needle is heated to a high temperature for up to 20 minutes. The heat thickens and seals the disk wall, reducing disk bulge and the related spinal nerve irritation. It's unclear whether this treatment is effective for back pain.

Prevention

You may be able to avoid back pain by improving your physical condition and learning and practicing proper body mechanics.

To keep your back healthy and strong:

Exercise. Regular low-impact aerobic activities — those that don't strain or jolt your back — can increase strength and endurance in your back and allow your muscles to function better. Walking and swimming are good choices. Talk with your doctor about which activities are best for you.

Build muscle strength and flexibility. Abdominal and back muscle exercises (core-strengthening exercises) help condition these muscles so that they work together like a natural corset for your back. Flexibility in your hips and upper legs aligns your pelvic bones to improve how your back feels.

Quit smoking. Smokers have diminished oxygen levels in their spinal tissues, which can hinder the healing process.

Maintain a healthy weight. Being overweight puts strain on your back muscles. If you're overweight, trimming down can prevent back pain.

Use proper body mechanics:

Stand smart. Maintain a neutral pelvic position. If you must stand for long periods of time, alternate placing your feet on a low footstool to take some of the load off your lower back.

Sit smart. Choose a seat with good lower back support, arm rests and a swivel base. Consider placing a pillow or rolled towel in the small of your back to maintain its normal curve. Keep your knees and hips level.

Lift smart. Let your legs do the work. Move straight up and down. Keep your back straight and bend only at the knees. Hold the load close to your body. Avoid lifting and twisting simultaneously. Find a lifting partner if the object is heavy or awkward.

Sleep smart. People with back pain have commonly been told to use a firm mattress, but recent studies indicate that a medium-firm mattress might be better. Use pillows for support, but don't use a pillow that forces your neck up at a severe angle.

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